Sr. Manager, Clinical Quality Review

Your Role

The Clinical Quality Review team reviews potential quality issues that are received by our members, providers, or are internally identified by staff. In collaboration with our medical directors, the team and follows up / reports results to the appropriate committees for further resolution. The Sr. Manager of the Clinical Quality Review team will report to the Director of Clinical Quality - Quality Management & Assurance . In this role you will be oversighting a team of RNs and administrative staff to ensure operational compliance with timeliness and reporting requirements. You will also complete report outs to various committees on team statistics. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work

In this role, you will:

• Provide supervision and ensure overall performance of team, while working to improve clinical performance outcomes
• Ensure that best practices are followed and develop innovative approaches to improve member receipt of appropriate services and provider communication
• Develop program including goals, activities and reporting structure to assess progress, barrier identification and recommendations for improved outcomes
• Direct assessment activities to determine overall cost and quality effectiveness of interventions
• Responsible for identification of, chartering and assignment of new projects with assigned Business Project Manager, and provision of progress reports on clinical improvement initiatives and projects to Quality Director and Quality Committees
• Responsible for operational and strategic oversight of the Clinical Quality Review activities, which spans Blue Shield of California and Blue Shield of California Promise Health Plans
• Manages team of coordinators and nurses to ensure clinical information/case related clinical research is obtained, reviewed, and reported out timely.
• Oversights/manages queues and case assignments, and allocates staff appropriately
• Works with BSC medical directors to conduct clinical reviews, assign severity leveling, and prepare cases for committee review (i.e. Specialty Reviewer, Peer Review Committee (PRC) or Credentialing Committee)
• Represents Clinical Quality Review team/activities in regulatory or accreditation audits, including preparing for file review audits, and presenting data to regulators

Your Knowledge and Experience

• Requires a bachelor's degree in Nursing, Public Health, or other related field
• Requires at least 10 years of prior relevant experience including 4 years of management experience
• Clinical Registered Nurse (RN) California license required; master's degree preferred
• Demonstrated experience in cross-functional operational leadership and in coaching, mentoring and guiding employees in areas related to change management and operational process improvement
• Demonstrated investigative, problem solving, critical thinking and assessment skills; requires working knowledge of industry related systems (including basic applications, EMRs and systems such as EPIC, CERNER, MediTech)
• Health care / Managed care experience, i.e. broad knowledge of current concepts, practices and procedures within the health care field, especially related to HMO, Medicare and Medi-Cal
• Excellent communication skills, both written and oral

Pay Range:

The pay range for this role is: $ 120120.00 to $ 180180.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

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